Good information was provided about the status
of healthcare overall and healthcare real estate

Gathering of healthcare experts to discuss
current topics

Great day - glad I was able to be here!

Great sequence of topics

Networking & like-mindedness

Open discussions

Good networking

Really enjoyed, thank you!

Breakdown of information and trends

Content was diverse and educational

The facility (Kaiser Center for Total Health)
which hosted

Networking time & amount of content panels
were great

Presentations were fantastic

Trends, stats

Interesting group of people and covered a lot
of different topics!

Variety of topics

Great participation by most major players in
the region

This (Rise of Women in Healthcare Leadership
Roles) was a fantastic panel that was as enlightening and
thought-provoking as it was entertaining

Great discussion!

Industry Partners

Takeaway Messages

May 30,
2019 - Washington, DC

Reported by Megan Headley, a freelance
writer based in Virginia. Headley is a frequent contributor to
healthcare publications including Patient Safety & Quality
Health, Health Facilities Management and Medical Construction &
Design, and manages content for the Association of Medical
Facility Professionals.

State of
Union: Next
Era of
Healthcare
Reform

Aaron Mauck, Senior
Director, Advisory Board Company

Just how serious is the physician shortage?
The president of Association of Vascular Surgery recently
estimated “50 percent of their professionals will be
retiring within the next 10 years.”

This biggest problem today: “Too much money
in the system and not enough bang for your buck.” High drug
and hospital prices are driving disruption. “Having a lot of
money in the system is prompting a lot of outside companies
to enter healthcare.

Amazon is likely to have big implications on
healthcare. In the near term, they’re aiming “to become a
supplier of choice for medical supplies.” Their acquisition
of PillPack is just a first step. Expect hospitals to win,
at least in the short term, as Amazon lowers supply costs.

The threat of outside disruption is also
pushing transformation within the industry. Today health
systems are not just buying up hospitals, but expanding
their footprint by acquiring nursing systems, ambulatory
surgery centers, etc.—and investing in disruptive tech such
as telehealth.

The next frontier: vertical consolidation.
M&A from other healthcare parties—think CVS, Cigna, Davita
Medical Group—is “recreating how the patient interacts with
the health system.” Insurers are reshaping how patients
interact with healthcare, giving them greater control of
costs. Expect to see expansion of care in retail sites in
the next 5 to 10 years.

Roughly 3% of ASCs in the U.S. are owned by
hospitals. Most others are owned by doctor groups or other
investors. And this poses a challenge for hospitals with the
ongoing shift of inpatient procedures to ASCs. The good news
is that many ASCs are interested in partnering with
hospitals.

Understanding
What’s
Driving
Demand for
Healthcare
in U.S. and
Mid-Atlantic
Region: A
Look at The
Most
Relevant
Numbers

We’re now dealing with functionally obsolete facilities.
Since 1990, there are now 500 fewer hospitals operating.

Emergency department volume continues to go up. This is
significant as half of all of a hospital’s admissions start
in the ED. However, the average length of stay metric has
become useless. Some patients might stay 1-2 days, others
for a significant duration. There’s truly no 5- to 6-day
average.

16% of the patients a doctor sees are new patients. 25% of
office visits are initial visits, versus follow-ups. That
stands to change. Just think: “What does telehealth do to
that number?”

The average medical visit is 121 minutes, but the time spent
with a doctor is on average 20 minutes. “We need think about
throughput.”

“Doctor visits are increasing faster than population as the
population ages.” Visits are project to increase 20% by
2030.

“D.C. has the highest concentration of doctors in the
country.” This is largely due to the area’s concentration of
medical schools, the leading impact of where a physician
chooses to practice.

“Everything starts at the doctor.” They shape the patient
experience and drive revenue. However, this experience is
changing. The physician shortage, for example, is expected
to see a deficit of over 121,000 physicians by 2030. The
2.4% decline in hours works from 2016 to 2018 equals the
loss of 19,200 doctors and tens of millions of patients not
seen a year. Plus, the way doctors operate is changing. “The
sole practitioner is disappearing.”

“Hospitals are becoming integrators of medical services …
it’s no longer just that building on the hill.”

Project Case
Study: Total
Health
Starts
Before Site
Selection

Sumrien Ali,
Design Manager, Kaiser Permanente

It’s time to look beyond simply place making. Consider the
care needs of community when making the real estate on where
to locate a facility.

One of the objectives of Kaiser Permanente’s Design
Excellence program is an emphasis on the community impact of
facilities. This includes not just visually integrating into
the community but also offering community health services.
For example, the Springfield, Va., MOB now in the design
phase went through a number of versions, but ultimately will
feature more expensive site to include outdoor space for
community enjoyment.

Other objectives include:

Cohesive: This speaks both to a building
design that fits the locality and brand consistency, but
also working with local government and nonprofits to
ensure the site meets community needs.

Adaptable and multi-functional: This
includes attention to more flexible furniture to
forward-thinking decisions on future expansions.

Connected: Open spaces and community
infrastructure strengthen community connections.

High-performing: The system has a focus
on balance with the local ecosystem.

Tips, Tricks
& Traps to
Avoid

This insight
comes from
the Tips,
Tricks &
Traps to
Avoid eBook.

Dave
Blackwell,
Healthcare
Segment
Manager,
Camfil

Trap
to
Avoid:
MERV-A
is a
much
more
important
filter
criteria
than the
standard
MERV
rating.
This has
been
used to
rate
filter
efficiency
for
hospitals
since
March
2016.

Tip:
Every $1
a
hospital
spends
on air
filters
it
spends
$7 on
energy
for the
fan.
Consider
changing
the
energy
spend.
By
buying
more
efficient
filters,
hospitals
can save
twice in
energy
what the
filter
costs.

Trick:
Hospitals
are
buying
too many
filters.
Most
still
change
pre-filters
every
quarter.
More
efficient
options
last
nine
months.

Kelly
Betts,
nora
systems,
inc.

Tip:
In any
resilient
flooring
solution,
the
seams
and
welds
are the
first
point of
failure.
This is
hugely
problematic
in
hygienic
spaces
such as
ORs.
Write
into
specifications
that the
flooring
installer
create a
mock-up
first.

Trap
to
Avoid:
Resilient
flooring
with
indentations
and
track
marks
can be
caused
by wet
set
adhesives
not
dried
long
enough
or
overwatering
of patch
and skim
compounds.
These
patches
can take
up to a
month to
dry.
Monitor
the
installer
to
ensure
the
necessary
dry time
is met.

Trick:
To get
the best
flooring
installation,
have the
GCs and
project
managers
challenge
the
flooring
contractor
to
include
proper
skim
coats
and not
cut
corners.
Then
ensure
they
evaluate
for
smoothness,
hardness,
and
strength
of bond.

Paul
Swan,
Director,
National
Healthcare
Systems,
Assa Abloy

Tip:
Just
because
your
supplier
sells
through
a
channel
doesn’t
mean
they’re
not an
excellent
resource.
Reach
out to
the
experts
to work
on
custom
solutions.

Trick:
Turn to
your
suppliers
to help
write
the
specification.
For
example,
Assa
Abloy’s
Virtual
Design
Guide
helps
show
project
costs
through
the
entire
life
cycle.

Trap
to
Avoid:
Don’t
chase
after
the
lowest
cost
solution.
The
total
cost of
ownership
is much
more
significant.

According to the ASHE 2018 Hospital Security Survey, 61% of
hospitals are increasing their security budgets. 50% of
hospitals are making changes due to a change in threat
level.

When doing a renovation or new construction, get your
security professional involved upfront. It’s important to
get prevention in through environmental design and access
control upfront. “It will cost you less in the end,” Lewis
says.

Mezewski notes that it’s important to ensure senior
management knows the magnitude of the security problem. “A
couple of years ago, the management didn’t know how many
runs we made to a code purple [violent patient]. Being able
to show them the numbers has helped me increase my staff.”

Environmental design is an effective and low-cost way to
thwart threats. For example, Mezewski says, “It doesn’t take
a lot of money to put in an extra rosebush. It takes a lot
of money to add a guard, camera, etc., when a rosebush would
do.” And while public space is great for community, it also
means more observers which can reduce potential threats.

“Video is a wonderful tool; it gives us many more eyes and
helps create situational awareness,” Mezewski says. However,
to be reliable, any technology needs regular upgrades and
patches.

Mezewski says his medical center has 500 soon to be 600
cameras—but no one security department can watch that many.
Instead, they “outsource” small segments of camera input to
specific departments. They also use the
LiveSafe app to encourage
personal reporting of incidents.

When asked whether they support armed guards, both Lewis and
Mezewski replied, “Absolutely not.” Evidence indicates
security officers with guns can be a risk in escalation and
pose potential for behavioral health patients to de-arm
guards.

Minimize access to public entrances. “Loading docks are one
of the problem areas now,” Lewis says, particularly from
contractors who may not have a badge.

Metal detectors can be helpful, but if you use them it has
to be at all entrances and manned—which becomes expensive.
For that reason, “they’re’ good but not that effective,”
Lewis says. However, AI-based technology is being tested
today to replace metal detectors, Mezewski says.

Rise of
Women in
Healthcare
Leadership
Roles

Left to
right:

Ashley
Schmidt, VP/Business
Development
Director,
HKS, and
President of
Women in
Healthcare

Kathy
Gorman, Executive
Vice
President of
Patient Care
Services and
Chief
Operating
Officer at
Children's
National
Health
System

Gorman
shares
that
the
male-dominated
faculty
at
Children’s
National
inspired
the
WATCH
(Women
at
Children’s
Hospitals)
mentorship
and
support
program
as
well
as a
Diversity
Council
driven
to
bring
more
women
and
diversity
into
the
workplace.

Whitmore
shares
that
UMMC
has
not
only
robust
leadership
training
but
also
diversity
training
that
focuses
on
how
to
treat
people.
With
so
many
people
at a
large
organization,
she
says,
“It’s
so
easy
to
be
unkind
to
someone
you
don’t
know.”

Johnson
says
the
MedStar
leadership
training
is
gender
neutral,
but
there
has
been
a
focus
on
proactively
mentoring
particularly
in
two
problem
areas:
predominantly
female-led
marketing
and
male-dominated
leadership.

Schmidt
says
there
need
to
be
three
main
areas
of
focus
for
improving
gender
equality:
professional
development,
culture
and
policy.
Culture
can
be
the
most
challenging,
she
finds.
“We
can’t
just
say
we
need
‘great
top-down
leaders.
We
need
tools
[policy]
to
help
move
the
culture.”

Panel
Question:
What is
your
advice
to young
women
looking
to
leadership
roles?

Find
a
mentor
you
can
connect
with,
Gorman
advises.
That
doesn’t
mean
it
needs
to
be a
woman.

“Men
are
better
at
self-promotion.
It’s
a
stereotype
that
has
roots,”
Johnson
finds.
She
encourages
others
to
not
be
cautious
if
they
want
to
try
something.
Above
all:
speak
up.

“Own
your
expertise,”
Whitmore
says.
At
the
same
time,
don’t
be
timid
about
what
you
don’t
know.
As
she
adds,
“Own
what
you
know
but
don’t
fake
it.”

Panel
Question:
What was
your
biggest
professional
disappointment
and how
are you
working
to
prevent
it
moving
forward?

Schmidt
shared
that
while
she
has
always
had
strong
male
mentors,
she
has
had
negative
experiences
from
women
leaders.
“I
find
as I
move
up
it’s
also
my
job
to
look
back,”
she
says.

Whitmore
shares
that
one
of
her
continuing
disappointments
is
that
as
she
puts
together
contractor
teams,
she
is
continually
across
the
table
from
a
very
homogenous
group.
“I
think
to
be
that
non-diverse
takes
work,”
she
says.

Johnson
says
her
biggest
disappointment
is
“the
lobster
syndrome.”
When
a
lobster
tries
to
crawl
out
of
the
tank,
the
others
hold
it
back
down.
She
sees
this
too
often
among
women
leaders.
“As
women
rise,
the
target
on
our
back
gets
bigger,”
she
says.

Gorman
says
her
biggest
challenge
as a
leader
is
hiring
the
right
people—but
also
recognizing
when
it’s
not
going
to
work
and
taking
steps
to
quickly
get
them
off
the
team.

Revista
reports
that
users
own 1.3
billion
square
feet of
MOB
space
(51%)
across
the U.S.
An
additional
1/3 is
owned by
REITs
(11%)
and
private
equity
(19%).

Today’s
MOBs are
moving
farther
from
campus
and are
seeing
larger
footprints,
with
more in
the 21
million
square
foot
range.

Healthcare
transactions
remain
healthy,
and
private
equity
is
leading
the way.
For
example,
the
largest
single
property
trade of
208 was
the $405
million
Memorial
Hermann
Medical
Plaza
sale.
Private
equity
is very
aggressive
in going
after
strong
tenant
occupancy
projects.
Investors
like
MOBs
because
“trends
are very
steady,
and they
hold up
long-term
during
economic
cycles,”
Hargrave
says.

The D.C.
region
is the
country’s
6th most
active
MOB
construction
market,
with
more
than
837,000
square
feet
under
construction.

“It’s
frustrating
right
now,”
Fischer
says.
“We’re
in a
highly
regulatory
industry.
It
doesn’t
surprise
me
occupancy
is high
we’re
functionally
full.”
Regulatory
delays
are
increasing
the
impact
of
inflation.
With six
years
between
planning
and the
start of
construction,
systems
are
finding
costs
are
several
basis
points
higher
than
expected.

Another
scheduling
challenge:
“We’re
very
litigious,”
Fischer
says.
Trammell
Crow is
building
a $100
million
memory
care
facility
in D.C.
and is
baking
into the
cycle
nearly
20
months
of
appeals.

“It’s so
difficult
to
deliver
healthcare
on a
timely
basis
because
of
regulations,”
Weinstein
adds. He
notes
that
Children’s
National
is
licensed
in D.C.
and
practices
in
Maryland
on
waiver
basis,
which is
renewed
annually.
They’re
building
a $45
million
facility
in
Prince
George
County,
Md., on
faith
that
this
license
will be
renewed.

The
Certificate
of Need
limit
presents
major
problems.
Weinstein
notes
that
getting
a CON
for
basic
systems,
such as
to
replace
an air
handling
unit or
emergency
generator,
can take
6-12
months
and
elevate
costs
due to
inflation.

In
planning
for
future
facilities,
Coursen
advises,
“Plan to
be
adaptable
over
time.
Technology
will
come and
disrupt
a lot in
the next
10-15
years.”

D.C. is
an aging
city,
Fischer
adds,
and most
residents
here
want to
be aging
in
place.
But
there
simply
aren’t
enough
doctors
and
nurses
to
support
this
trend.
“I think
these
issues
will get
worse
and I
think
our
buildings
are
getting
more
complex,”
he says.

Weinstein
notes
systems
have to
address
cost
pressures.
“We’re a
$1.5
billion
operation
working
on a 2%
margin.
What
other
industry
would be
satisfied
with
that?”
he says.

Clinics
and MOBs
are
treated
as
business
occupancies.
But once
a
surgery
renders
people
incapable
of
self-preservation
via
anesthesia,
regulations
get
tighter.
Life
Safety
Code
starts
stricter
regulation
with
four
people
under
anesthesia;
CMS sets
this
limit at
one
person.

Ambulatory
healthcare
occupancies
have
many
additional
requirements
not
applicable
to a
standard
business
occupancy:
need to
be fully
sprinklered,
needs a
fire
alarm
system,
and
needs to
comply
with
NFPA 99
and FGI.

Almost
all
states
use a
version
of the
International
Building
Code but
requirements
still
vary
widely.
For
example,
Pennsylvania
uses the
2015
edition,
while
Philadelphia
uses the
2018
edition.

The
intersection
of
integrated
project
delivery
(IPD),
Lean
construction
and
design
principles
and
technology
leads to
successful
projects:
projects
that are
on time,
within
budget,
achieve
project
goals
and
generate
owner
satisfaction.
Let’s
define
these
tools:

IPD:
A
multi-party
form
of
integrated
agreement.
This
high
risk,
high
reward
design
approach
depends
on
true
collaboration
to
be
successful.

Lean:
A
method
and
tools
for
increasing
value
by
decreasing
waste.
Its
foundation
is a
respect
for
people.

In IPD,
Killebrew
says, “I
think
all of
the team
members
carry
some
level of
responsibility,
but our
industry
knows
the
owner
ultimately
makes
the
decisions.”

Too many
businesspeople—including
owners,
architects
and
contractors—believe
you only
succeed
by
“beating
up” or
“squeezing”
others.
Someone
has to
lose for
you to
win.
This
hurts
their
ability
to
collaborate.
You
can’t
ignore
this—acknowledge
it to
move on.

One of
the best
known
IPD
concepts
is the
Big
Room.
But
Killebrew
says,
“In the
project
I’ve
been
working
on it
was one
of the
bigger
stumbling
blocks
because
people
didn’t
know how
to
operate
in it.”
However,
absent
the big
room
collaboration
plummets.

A key
takeaway
from
this
combination
is that
there is
a
success
matrix
for
projects.
There is
a sweet
spot and
it
works.

Large Scale,
Real Time
Savings with
Technology
Breakthroughs
via Modular
and
Prefabrication
Models

“The
obsolescence
of
today’s
building
design
is
becoming
an
issue.
Flexibility
and
adaptability
need to
be top
of
mind,”
Gray
says.

This was
key for
a
Polyclinic
project
in the
Seattle
area.
The
project
needed
about
62,000
square
feet,
but
found no
developable
medical
space
that fit
its
requirements.
After
touring
the
Amazon
headquarters
and
seeing
its
unique
design
where
modular
walls
could be
moved as
easily
as
cubicles,
they
decided
to make
use of a
Class B
space.
The key
was an
integrated
wall
system
that
used
vacuum
plumbing.

Healthcare
has to
look
outside
the
industry
for
innovation.
Anywhere
there’s
refrigeration—think
Target
and
Trader
Joe’s—vacuum
pluming
is
commonly
used to
get out
condensation.
With
this
system
everything
floats
above
the
slab—in
the
ceiling
plenum—so
moving a
sink is
as easy
as
moving a
light
switch.

Adapting
this
space
would
have
meant a
$500,000
hit
using
conventional
systems
due to
the
inadequate
sewer
lines.
But with
the
plumbing
system’s
timed
release,
they
could
use
existing
sewer
lines.

A building is not just a building. It’s a physical
manifestation of an organization. And it has strategic,
operational and financial value. Location is key.

“You need to not only build a system but dynamically manage
it, constantly realizing the needs of marketplace and
finding ways to differentiate.”

“We’re not truly a market defined by behaviors because of
the factor for need,” Barmada says. For that reason, the
hospital isn’t going away. But “we’re very competitive” now.
That drives the need for new methods to analyze locations
for healthcare real estate. For example:

The Innovation District. In the ’60s,
Silicon Valley was a tech transfer park for Stanford.
Now we’re starting to see this type of lab-to-market
acceleration driving healthcare. For example, the
Children’s National Walter Reed Pediatric Innovation
District, partnered with JLABS to develop pediatric
research.

Huff’s Gravity Method is based on
the premise that customers will utilize goods or
services from a specific location as the size of that
location and density of services grows and distance or
travel time shrinks. The Baylor, Texas A&M, UT, M.D.
Anderson: Texas Medical Center mega-campus is a
biomedical research hub. That attracts people from all
over the world.

The Health Village model, such as
ProMedica’s Ebeid Institute focuses on addressing social
determinants of health and screening and intervention to
drive wellness.

The Augmented Clinic focuses on data.
Verily (the health arm of Google parent Alphabet) is
over-investing in technology so it can track social
determinants, the efficiency and efficacy of certain
programs, and more. With the data they’re collecting
they’re aiming to build the preeminent database on
treatment.